Provider Demographics
NPI:1841611779
Name:LEGACY DRUGSTORE CORP.
Entity Type:Organization
Organization Name:LEGACY DRUGSTORE CORP.
Other - Org Name:LEGACY DRUGSTORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AZARAHI
Authorized Official - Middle Name:
Authorized Official - Last Name:CARDOSO-GALVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-443-3555
Mailing Address - Street 1:4700 NW 7TH ST
Mailing Address - Street 2:1
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2252
Mailing Address - Country:US
Mailing Address - Phone:305-443-3555
Mailing Address - Fax:305-443-3522
Practice Address - Street 1:4700 NW 7TH ST
Practice Address - Street 2:1
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-2252
Practice Address - Country:US
Practice Address - Phone:305-443-3555
Practice Address - Fax:305-443-3522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-19
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH273033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2143423OtherPK